Provider Demographics
NPI:1881356681
Name:GIBSON, MACHELISE SIMONE
Entity type:Individual
Prefix:
First Name:MACHELISE
Middle Name:SIMONE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3171 HUNTINGTON LN FL 33810
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-4756
Mailing Address - Country:US
Mailing Address - Phone:863-327-7550
Mailing Address - Fax:
Practice Address - Street 1:145 E EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4014
Practice Address - Country:US
Practice Address - Phone:863-619-2809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-22-61339103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst